Markesan, WI

Markesan Resident Home

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1130 N Margaret, Markesan, WI

(920) 398-2751

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

35

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1995-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.99

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

3.15

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

4.70

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.55

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

4.34

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.74

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.10

CMS adjusted RN staffing hours

Adjusted total hours

5.24

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,921

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

42.11

Composite VBP score used to determine payment impact.

Payment multiplier

0.9950

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.96

Baseline 18.62% · Performance 19.60% · Measure score 3.96 · Achievement 3.96 · Improvement 0

Healthcare-associated infections

4.03

Baseline 5.68% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 0

Total nurse turnover

3.35

Baseline 43.75% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0

Adjusted total nurse staffing

5.51

Baseline 3.95 hours · Performance 4.64 hours · Measure score 5.51 · Achievement 5.51 · Improvement 3.31

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.33%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 7.4%
Discharge to community	52.36%	50.57% 1.8 pts better	No Different than the National Rate · Eligible stays 58 · Observed rate 51.72% · Lower 95% interval 39.05%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 32 · Denominator 32
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 32
Discharge self-care score	37.04%	53.69% 16.6 pts worse	Numerator 10 · Denominator 27
Discharge mobility score	40.74%	50.94% 10.2 pts worse	Numerator 11 · Denominator 27
Pressure ulcers or injuries, new or worsened	3.13%	2.29% 0.8 pts worse	Numerator 1 · Denominator 32 · Adjusted rate 3.42%
Healthcare-associated infections requiring hospitalization	6.63%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 3.21%
Staff COVID-19 vaccination coverage	0.8%	8.2% 7.4 pts worse	Numerator 1 · Denominator 125
Staff flu vaccination coverage	73.23%	42% 31.2 pts better	Numerator 93 · Denominator 127
Discharge function score	66.67%	56.45% 10.2 pts better	Numerator 18 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 21 · Denominator 21
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.7% 4.3 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	3.2% 0.5 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.7% · Q3 3.6% · Q4 4.0% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	5.0% 4 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	10.5%	4.9% 5.6 pts worse	5.4% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 16.0% · Q3 17.4% · Q4 0.0% · 4Q avg 10.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.6%	16.6% 1 pts better	19.6% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 16.0% · Q3 17.4% · Q4 19.0% · 4Q avg 15.6%
Percentage of long-stay residents who received an antipsychotic medication	6.5%	16.7% 10.2 pts better	16.7% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.5% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	16.4%	21.1% 4.7 pts better	16.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.6%	17.3% 1.7 pts better	14.9% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 17.4% · Q3 4.8% · Q4 10.0% · 4Q avg 15.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	2.3% 2.3 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	3.0% 0.2 pts better	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.4%	25.5% 5.1 pts better	19.8% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 11.3% · Q3 20.7% · Q4 18.3% · 4Q avg 20.4%
Percentage of long-stay residents with pressure ulcers	1.1%	5.5% 4.4 pts better	5.1% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.8% 13.2 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	4.3%	15.0% 10.7 pts better	12.0% 7.7 pts better	Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.7% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.8%	82.2% 13.6 pts better	79.7% 16.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	22.7% 3 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 14.8% · Expected 17.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-12 · Fire 2025-02-12

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2023-12-20 · Fire 2023-12-20

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-11-02 · Fire 2022-11-02

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-12

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-03-03

F · Potential for more than minimal harm 2025-02-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-07

E · Potential for more than minimal harm 2025-02-12

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2025-03-03

F · Potential for more than minimal harm 2023-12-20

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-01-08

E · Potential for more than minimal harm 2023-12-20

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-20

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-20

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-01-08

F · Potential for more than minimal harm 2022-11-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-11-02

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2022-11-08

E · Potential for more than minimal harm 2022-11-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-09

D · Potential for more than minimal harm 2022-11-02

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2022-11-28

D · Potential for more than minimal harm 2022-11-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-11-02

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2022-11-30

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-12

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-03-06

E · Potential for more than minimal harm 2025-02-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-06

D · Potential for more than minimal harm 2025-02-12

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-03-06

D · Potential for more than minimal harm 2025-02-12

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-03-06

F · Potential for more than minimal harm 2022-11-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-22

Penalties and ownership